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Clinical Notes Summarising in Primary Care

Workshop Agenda:

Session 1:

  • Welcome, introductions and objectives
  • The purpose and significance of summarising in primary care
  • What is required before you start
  • The summarising process

Session 2:

  • The importance of Episodicity
  • Use of Problems (if appropriate)
  • Hints and tips on data entry
  • The importance of an accurate Summary
  • Records received via GP2GP
  • Quality Assurance and maintenance

Session 3:

  • Hints and tips on coding correctly
  • CARAT
  • Practical exercise – summarising a set of patient notes.
  • Guidance on data entry for summarisers (SystmOne only)

Session 4:

  • Practical exercise continued
  • Action planning

Workshop Objective

This practical and interactive workshop has been designed specifically for summarisers within primary care to enable them to understand the purpose and significance of summarising both new patient records and incoming correspondence.  The workshop will provide a suggested step by step process for summarising new patient records.  Information provided on this course is in accordance with the Good Practice Guidelines for GP electronic patient records V4 (2011).  Delegates will have the opportunity to  summarise a set of patient notes.

DELEGATES MUST HAVE A GOOD WORKING KNOWLEDGE OF READ CODES/ CTV3 CODES PRIOR TO ATTENDING THIS SESSION.

Who should attend

Any practice staff new to, or currently summarising patient notes.

Workshop Duration

Full Day - For a single practice team only.